What the Gates Foundation’s $1 Million Condom Says About Global Health

By Patrick Brennan —
March 26, 2013

The Bill & Melinda Gates Foundation is one of the world’s largest charitable foundations, and has devoted much of its $30 billion endowment to the challenges of global health and extreme poverty. Over the past decade, it and other massive philanthropic commitments from Western governments (ahem, George Bush) and wealthy individuals have made real progress on some global-health issues. One way they do this is by funding innovative and wholly new approaches to fighting poverty and disease, which is how we get this project:

We are looking for a Next Generation Condom that significantly preserves or enhances pleasure, in order to improve uptake and regular use. Additional concepts that might increase uptake include attributes that increase ease-of-use for male and female condoms, for example better packaging or designs that are easier to properly apply. In addition, attributes that address and overcome cultural barriers are also desired. . . .

A few examples of work that would be considered for funding:

Application of safe new materials that may preserve or enhance sensation; Development and testing of new condom shapes/designs that may provide an improved user experience; Application of knowledge from other fields (e.g. neurobiology, vascular biology) to new strategies for improving condom desirability.

This project is part of a series of “exploration” competitions in the Gates Foundation’s “Grand Challenges in Global Health” program, which gives first-round grants of $100,000, and follow-up grants of as much as $1 million, to people who can develop groundbreaking solutions to, well, grand challenges in global health (you can read about the existing projects in the program’s latest annual report; more than 800 grants worth more than $100 million have been awarded).

Unfortunately, though, this isn’t exactly the kind of innovative thinking the Gates Foundation is ostensibly trying to promote. Their proposal laments that the condom has been essentially unchanged as a technology for 50 years, but the strategy of handing out condoms to stop the spread of HIV has been around for awhile, too, and has turned out to be remarkably ineffective at halting the pandemic’s spread. Condoms have been effective in a few high-risk environments, such as among prostitutes in Southeast Asia, but contraception-focused programs have been extremely ineffective in the place that matters most, Africa — the tide of the pandemic has only been turned by changing behavior and providing treatment, which reduces the risk of transmission substantially (I discussed this problem in a recent NRO piece, and Kathryn Lopez did an interview about it with HIV researcher Edward Green in 2011).

There are plenty of reasons why condoms aren’t faithfully used in Africa (and in other high-risk environments), despite being relentlessly evangelized and dropped by the million all across the continent, and studies suggest they do include the main problem the “Next Generation Condom” is supposed to address, concerns about the, er, user experience, in addition to the many cultural issues that make people uninterested in or even hostile to using them. I suppose it’s possible that technology could address that complaint, or possibly make condoms, as the Gates proposal also suggests, somehow easier to use (as if confusion were really the problem here), and that people at risk would start using them properly and faithfully. But technology can’t solve all public-health problems, especially, it’s seemed, one like HIV/AIDS. The Gates Foundation itself has already supported the development of other kinds of prophylactics, such as vaginal gels, that many thought might be more widely adopted, and they definitely haven’tbeen.

It’s not easy to get people in traditional or foreign societies to adopt Western public-health interventions, and a technology that requires consistent, faithful use is especially difficult. Situations vary, of course: Patients who have access to anti-HIV drugs tend to take them pretty faithfully, despite serious side effects, because many are essentially bedridden until they receive the life-sustaining drugs. For diseases where treatment’s effects are less obvious, though, as the WHO has found out with tuberculosis, which can go dormant or disappear before being truly cured, patients often give up on treatment. Global-health workers have found that close observation and community-based efforts, like hiring local workers to monitor a few patients each, can be quite effective at improving treatment rates (the somewhat successful WHO TB program is called DOTS; a main limiting factor has actually been the range of available drugs, not the techniques).

In these respects, the West’s longtime obsession with condoms as the first-line solution to the HIV pandemic made little sense: It was merely a prophylactic that offered no other health benefits while confronting huge cultural barriers like other interventions. The Gates Foundation is betting that someone can overcome those barriers with a simple technology, but it seems unlikely that’ll be enough — leaving the faithful take-up of condoms to other methods, when a sexually transmitted infection by nature is almost impossible to address with the kind of community-based monitoring that encourages faithful use of other interventions. The suggestion that more pleasurable contraception might help just epitomizes the global-health establishment’s devotion to the ideals of non-judgment and sexual liberation over discouraging risky behavior and providing treatment that actually saves lives.